COMMENTARY

Health Disparities in Dermatology: Making a Change

Candrice R. Heath, MD; Susan C. Taylor, MD; Lynn J. McKinley-Grant, MD

Disclosures

December 03, 2020

This transcript has been edited for clarity.

Candrice R. Heath, MD: Hello, everyone. This is Dr Candrice Heath, your guest host for the Dermatology Weekly podcast. I would like to thank our special guests today who have joined us for a COVID-related conversation.

With us today are Dr Susan Taylor, the Sandra Lazarus Professor of Dermatology at the University of Pennsylvania, where she also serves as vice chair for diversity, equity, and inclusion for the Department of Dermatology. We also have Dr Lynn McKinley-Grant, who is serving as the president of the Skin of Color Society and who also is an associate professor of dermatology at Howard University. Thank you so much for joining me today.

Susan C. Taylor, MD: Pleasure.

Lynn J. McKinley-Grant, MD: Great to be here.

Heath: Today our topic of discussion will be health disparities in dermatology, which were brought to the forefront during the pandemic. This is definitely a hot topic and we have some great guests. I look forward to hearing what you have to say.

What are some examples of the health disparities that have been brought to light during this pandemic, Dr Taylor?

Taylor: Thank you, Dr Heath, for that important question. During the pandemic, while we were all quarantined and were able to view the social unrest and the marches around racial/ethnic inequalities in the United States, people began to think and really examine the differences and the inequities.

The one that was foremost in our minds was that of COVID — the fact that Black and brown people disproportionately were affected by COVID and died from COVID. It is a complex situation. I think some of it has been demonstrated to be genetic, but also it's been demonstrated to be related to the frontline work that many Black and brown people have done. That opens the whole issue of workforce diversity and equity.

Heath: Dr McKinley-Grant?

McKinley-Grant: I'd like to lead with what Dr Taylor was talking about, which was the workforce. With the workforce comes the need for public transportation. That's been a source early on of COVID and the close contact on the trains, buses, Ubers, and now the need to do the driving. That's another inequity that has happened.

Also, things like food security: Getting food; if it's not in your neighborhood, having it delivered; and the cost of things have brought out a lot of inequities. We've all had to use telehealth, and I saw a huge inequity in terms of just Wi-Fi access and internet access. Their phones are just for 10 minutes, an hour, or 2 hours. They miss their appointments. They don't have smartphones. The school system now is bringing out the same inequity. But trying to get patients treated with what seemingly was a great idea because it did really increase access in terms of dermatology... You could look at the skin, and examine, and recommend, and write prescriptions, but you do have the issue of people not having the internet, another role of access.

Taylor: I mentioned the workforce and how many brown and Black people are in the service industry and had to go to work during COVID and could not quarantine. That raised for us, within dermatology, the ability to look at the workforce in our own specialty. Within dermatology, we know and it's been well documented, that only 3% of dermatologists are of African descent, as opposed to 13% of the United States population. For the Latinx population, there are 3% dermatologists as compared to 17% of the United States population.

Those of us in dermatology and in academic centers and various organizations have begun to examine and think about that: Why is that a truth and what can we do to rectify that? It has far-reaching implications. Diversity in our dermatology workforce, and in an all workforces in medicine, leads to better care.

There are studies that have demonstrated that with race-concordant visits — that is, where the patient is, let's say, of African descent and the physician is of African descent — the patient is more satisfied, they tend to be more compliant, and they get better.

We also know that minority dermatologists work in underserved communities and that they accept public insurance or no insurance at all. They care for patients with particularly poor health status and are really committed to caring for patients of their own race. It behooves all of us to examine why this is the case, 3% and 4%, and how we can impact or make a change and increase racial ethnic diversity within the specialty of dermatology.

Heath: With that backdrop of all of the inequities that were displayed during the pandemic, Dr McKinley-Grant, you started to give us some examples of that. Do you have any other additional dermatology-specific health disparities that you think our listening audience would be able to relate to?

McKinley-Grant: Well, it's interesting that everyone's saying that we've just recognized that there are health disparities in dermatology with COVID, but many of them existed previously.

Heath: You're exactly right. I want to just take a full pause there and have Dr McKinley-Grant repeat that, because there have been people at the forefront of this for decades and decades.

This is a COVID-related conversation because it seems like the wool has been removed from the eyes and now people can really start to relate to these things. This is one of the more positive things that's come out of the pandemic, so it is just the time to really think about these things. I'm sorry — go ahead, Dr McKinley-Grant. I just had to really emphasize that.

McKinley-Grant: I had the exact date memorized, but I can tell you, it was April 2020 that the health disparities in America were recognized. Many of those are, in terms of treating patients, access to care: where the dermatologists are located, who they are; as Dr Taylor said, the lack of the workforce diversity. I think people of color prefer to see other doctors who they feel will have the training to deal with their skin.

We have still the health disparity of teaching physicians and medical students about how to diagnose disease in darker skin types. That's been demonstrated with COVID, also, of people unable to see erythema of the alleged COVID toes, and erythema of other infections that can occur and are life-threatening. I think many of the disparities are just accentuated. The diagnosis of disease is one that is of utmost importance to me because that's the one that saves lives and decreases morbidity.

Heath: Dr Taylor, why would you say that health disparities should really matter to all dermatologists? Why is this a topic that all dermatologists should care about?

Taylor: We don't live in a silo. We all must care about this issue because we're all responsible for the issue and we're all responsible for the solution. We're part of a whole. The analogy has been made that we're not 50 states; we're the United States.

Similarly, within dermatology, if we have a problem that's significantly negatively affecting our patients, then it is the responsibility of all of us to change that. When we are united, we can effect change. I think that throughout the country, there is an openness now to discuss, to have conversations and dialogue and look toward solutions.

I'm very proud of our major organizations, be it the American Academy of Dermatology (AAD), the Women's Dermatologic Society, the Society for Investigative Dermatology, the Association of Professors in Dermatology, and the Skin of Color Society. They've been doing this work for 20 years. Everyone is really rising to the occasion and making concerted, great efforts to change these disparities.

Heath: Dr McKinley-Grant, what kind of charge would you give to all dermatologists that can really rally them around this topic of health disparities?

McKinley-Grant: The charge would come in terms of really treating all patients equally and getting the training to give quality care to all patients. Right now, we're in the season of looking at and accepting for training new dermatologists. I think there is a responsibility on the academic side to really look at the diversity of the applicants and the high quality that they're going to be seeing, and then to be able to accept those applicants into dermatology.

It is an inclusive specialty. I think every program will benefit from training more. In terms of the dermatologists in practice, I found during COVID, when offices had to be closed, that it was very stressful for dermatologists of color who were in practice. I just had not seen the level of depression because everyone loves dermatology. There's a passion of dermatologists who practice, and we just have a passion for the treatment.

I would encourage doctors just to be more open and to increase access. Saying that, you have to really look at insurances and what insurance you're accepting because that will increase access to dermatology. The important thing is about educating and then also mentoring residents, younger dermatologists, or younger medical students, to get people into dermatology or even to focus on the skin as a major, vital organ.

Heath: Dr McKinley-Grant, I know that you are currently the president of the Skin of Color Society and ironically — well, not so ironically — we also have Dr Susan Taylor, who founded the Skin of Color Society. Since you're the current president of the Skin of Color Society, when you were elected to your current office, I'm sure that preparing for a pandemic was not on your radar at all.

How have you been able to use your leadership platform to begin to tackle some of these disparities in dermatology?

McKinley-Grant: Well, I think you're absolutely right. This was not on the radar screen at all, and I think even the vision of the role that I've been playing was not on the screen at all. It's been very eye-opening, where people are recognizing this need for more diversity in dermatology. They are coming to us. This is a source; you guys have done a great job with the mentoring, with research, with education.

There's been an increase in funding with what we've been calling the diversity fund. We've been able to do more and we continue to be more visible. We're doing a series now with The New England Journal of Medicine group, and that has been very successful. We've been able to have many leaders who have done a lot of research and a lot of work, and it's been a way to get the word out about skin of color and pigmented skin. It's kind of like we have a base for people to come to, to get education and to increase research and mentoring. We'll continue to do that.

Taylor: I am tremendously proud of the around-the-clock work that Dr McKinley-Grant has been doing for the past year on behalf of the Skin of Color Society. I'm sure there was no way for her to anticipate or prepare for the pandemic.

She has really taken this organization to levels and heights that I had not dreamed of when I first started it. When you look at the degree of funding that has been increased for research related to skin-of-color issues, that has increased exponentially under Dr McKinley-Grant's leadership.

There's now a significant $100,000 career grant that's offered in addition to the other grants. When we think about exposure and education of the dermatology community, as well as the whole medical community and lay people, that has taken off exponentially with this series in conjunction with The New England Journal of Medicine.

There are other huge initiatives that she's not announced yet that the Skin of Color Society is involved in — again, around education. The mentorship program has been increased. All of this has been under her watch and it has taken this society to completely new levels.

I want to thank her. We all have a debt of gratitude to her, not to mention the collaboration with Cutis and MDedge, which we are a part of today. Thank you very much, Dr McKinley-Grant.

McKinley-Grant: Well, thank you. This has not been a job done alone. I have to thank Dr Heath also. Thank you, Susan, too, for guidance and just being there and starting the society.

We have an amazing team of co-chairs of different committees, and everyone is putting in such great efforts at reaching out to other societies and other groups, and bringing the Student National Medical Association (SNMA), the National Medical Association (NMA), and the AAD. We're all working together. They're just these little fingers that are out there and pulling everyone in to address the issue of skin of color. Thank you for those comments.

Heath: Yes, I think those were comments and accolades that are definitely well placed. I thank you again for that.

I imagine that all of the early supporters of the Skin of Color Society, including Cutis and MDedge, which is now under the umbrella of Medscape, should be sticking their chests out to say we were supporters from the beginning, from early on. I hope that we can give them that distinction as well, but we also welcome the new supporters.

I definitely want to get back to Dr Taylor on this question about using your current leadership roles that you have during the pandemic to really start to tackle some of these issues.

Taylor: Well, I am just absolutely delighted to report that the AAD, which is our largest organization for dermatologists and for our patients, has been at the forefront in instituting change. I am currently the vice president of the AAD.

Some of the initiatives that have started include a skin-of-color curriculum for dermatology residents. As many people know, there is, for many programs, a paucity of training related to skin of color. At some programs, residents may not see people with skin of color. Over the past 6 months we have created a committee. Dr Heath is on the committee and Dr McKinley-Grant is too.

We have developed modules that the residents will have access to. We anticipate initially between 60 and 100. They include topics from skin of color, inpatient/outpatient surgery, pediatrics, and cultural competency. This is really under the auspices of the AAD.

We have created a work group of the AAD that's looking at how to instruct our members to better take photographs of skin of color and how to create a photo bank of photographs for skin of color.

The Diversity Committee of the AAD has just passed multiple initiatives to increase the pipeline in dermatology to support several programs — not only the AAD Diversity Mentorship program, but the Nth Dimension program, to bring along that next generation of diverse trainees to enter the field of dermatology.

Those are just a few of the initiatives of the Academy around diversity, and I am just absolutely thrilled with it. Let me also point out that the Academy has partnered with the Skin of Color Society, the Association of Professors in Dermatology, the Women's Dermatologic Society, and the dermatology section of NMA. Many of these efforts are collective efforts, going out to the SNMA and the NMA to talk to young people to get them interested in dermatology.

COVID has allowed an atmosphere and an environment of openness and of wanting to participate in solving these problems.

Heath: We have a very wide listening audience, and this is what I love about dermatology. We have colleagues who are in private practice. We have colleagues who are in academics. Of course, we also have our dermatology residents who are rising through the ranks to become dermatologists.

In each of those areas, there are some unique opportunities to really make an impact on health disparities. I'll start with Dr McKinley-Grant, just thinking about things that you could advise some or all of these groups on, using their unique positions to make an impact on health disparities in dermatology.

McKinley-Grant: The group I'll start with, because they're on my mind a lot, are the residents. Training them in terms of ways of thinking and giving them as much exposure to patients of color, including creating opportunities for them to do observer shifts. Or if they're in an area where there aren't many people of color, to get that experience early while they're in training, because I think it's very important.

Also, at these other levels, in terms of dermatologists and faculty, is getting people more accepted into dermatology. I think the ideal programs have been these diversity positions that have been created — two programs only now, Duke and University of Pennsylvania — to work on getting residents. These types of programs improve the number of residents of people of color who are attracted to the programs, but they also encourage the curriculum to change too. It's getting more training and then being able to bring in more people who are interested in skin of color into residency programs.

Heath: Dr Taylor, do you have any other thoughts on what the other groups can do, like private practice or those in academics?

Taylor: Yes. I'm in academics now, but for 27 years I was in private practice. What I found very helpful was to create mentorship opportunities for college students and medical students, where they would come and spend various periods of time with me in my office. They would shadow me so that they would have an opportunity to observe patient care. They would shadow me when I saw research patients, but also I would spend time talking to the college student or the medical student and answering all of their questions and exposing them to dermatology. If you're in a private practice, you can most definitely mentor young people, and that can go very, very far.

Additionally, I think it's important for private-practice physicians to understand that they can impact in multiple ways. Perhaps you don't have the time to mentor individual students. Well, it could be very impactful to donate money to the different organizations that have mentorship programs, whether it's the Skin of Color Society, Women's Dermatologic Society, or the AAD. You can earmark your funds for mentorship programs, and that is incredibly important and incredibly impactful because then the organizations can reach more students.

Do you have a couple of interesting cases that could be written up into case series or case reports? That's a perfect opportunity for a medical student to build their publication portfolio. Individuals in private practice don't get a pass. You can make just as significant an impact as those in academics.

Heath: Dr McKinley-Grant, do you have anything to add to that?

McKinley-Grant: I'm going to put this on Dr Taylor. She has done an incredible, amazing job of mentoring — and not just mentoring, but getting people to success. They've gone from students, they've published — I'm sure it's helped with her publications, too — they go on to residency, they become whoever they are. I don't know if you have any chairs of departments yet.

There is an effort, and I can't imagine how she even has the time to do this, but it is a definite priority. She's used her own funds to pay for a fellowship for a year. It is definitely the way.

One of the things that we don't get as particularly African American, in my experience, we don't early on get that kind of mentorship. In medical school, you may not be the one chosen to work with Dr So-and-so to write the paper. We are here and we want to help. I think Dr Taylor has been the model of this and we have to keep putting it out. Mentioning the mentorship, if you don't have time to mentor, you can pay for a mentorship. I think these are solutions. We want to look at what are some of the solutions, and I think she's come up with many. I really appreciate that.

Taylor: Thank you. Thank you very much.

Heath: As we close this COVID conversation on health disparities in dermatology, I would like to give both of you the opportunity to give some closing remarks. I'll start with Dr Taylor and then I'll end with Dr McKinley-Grant.

Taylor: Disparities in healthcare and in dermatology are an important issue for all of us, whether you are of a diverse background or not. Ultimately it's about commitment to these issues, to improving patient care, to improving the lives of people. If you are not sure what you can do, call me, email me (Susan.Taylor@PennMedicine.upenn.edu). If you want to do something but you don't know what it is, I can plug you in. It takes an effort of all of us to make a difference.

Heath: Dr McKinley-Grant, any closing remarks?

McKinley-Grant: I'm going to try to end optimistically, too, about COVID. It sounds like with the vaccine, things may turn around. It might be a year, but at least there's a little bit of hope there. If we are going to be inward and inside and not with people as much, there's still a lot that can be done.

You may not be out, but you can still make a lot of change. I think it will be a time that we can come together, we can provide opportunities for people of color who want to do some academic work. It may be an opportune time. I think efforts to change health disparities can be made during this... I'll call it an inward time of COVID.

Heath: I would like to thank both of you, Dr Taylor and Dr McKinley-Grant, for joining me on the podcast for another COVID-related conversation. This time, it was on health disparities.

For the listening audience, you already know who I am, but this is guest host Dr Candrice Heath, your favorite fun, board-certified dermatologist, your go-to girl for everything healthy hair, skin, and nails. Thank you for joining me for a series I call COVID Conversations with Dr Candrice. See you next time.

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